Root C t Cause An Analysis Presented by: Isaac Garcia, RCC Objec - - PowerPoint PPT Presentation

Root C t Cause An Analysis

Presented by: Isaac Garcia, RCC

Objec ectives es

• Define Root Cause
• Understand how an organization benefits from

root cause

• Learn how to determine root cause

using the “5 Why” method

• Learn how to determine, implement,

and prove corrective action using a 5-step problem solving process.

Definiti tions – Root Cause

A root cause is an initiating cause of either a condition or a causal chain that leads to an outcome

• r effect of interest. The term denotes the earliest,

most basic, 'deepest', cause for a given behavior; most often a fault.

Definiti tions – Root Cause An Analysis

A Root Cause Analysis is a wide range of approaches tools and techniques used to uncover causes of problems

When a and Why S Should Root C Cause An Analysis b be Perf rform rmed?

• If we do not get into the details of a problem, we

can expect it to re occur

• Any issue can benefit from a root cause analysis
• The depth of the analysis depends on the possible

frequency and possible severity of the problem

Benefits of R Root Cause An Analysis

• Problems are not repeated
• Often multiple problems have the same root cause
• Solutions determined may solve other problems
• Analysis improves communication groups

Definiti tions – Prob

• blem

em S Solving g Proc

• ces

ess

The process of working through details of a problem to reach a solution. Problem solving may include mathematical or systematic operations and can be a gauge of an individual's critical thinking skills

Correc ective A e Action

• n Proc
• ces

ess

• 1. Identify a problem (may be a claim, claims, etc)
• 2. Contain the problem and take immediate action
• 3. Analyze the problem and define the root cause
• 4. Develop and implement corrective action plan
• 5. Complete and validate corrective action plan

Crea eate S Safety Com

• mmittee

e – Pre e step ep

• Should consist of people who are knowledgeable.
• Small group (4 to 8), more than this will slow the

process.

• Must be empowered to make

changes, management support

• Should have a chair
• Team membership may change

based on needs. Team may become smaller or larger

Iden entify the Prob

• blem

em – St Step ep 1

• Who? – individuals, departments, or public associated

with problem

• What? – problem statement or definition
• When? – date and time problem is occurring
• Where? – location (area, facility, road, etc)
• Why? – any know explanations
• How? – how did the problem happen (root cause) and

how will it be corrected (corrective action)

• How many? – size and frequency of problem

Take Immediate Action – Step 2

• Isolate the problem
• Usually Band Aid /fixes
• Reassigning tasks
• Re inspecting work
• Only temporary until

corrective action is implemented

• Verify that immediate action

is effective.

• New problems should not

arise from temporary action

Types es o

• f Correc

ective A e Action

• n
• Immediate
• Action Taken to quickly fix the impact of a problem so no

further problems occur.

• Permanent
• Root Cause Corrective Action
• Action taken to eliminate an error in a process.
• Preventative
• Systemic Root Cause Corrective Action
• Action taken to prevent the error from recurring in any

process.

Types es o

• f Correc

ective A e Action

• n – Scen

enario

• 1

The public works department has submitted multiple workers’ compensation claims with missing information.

• Immediate Corrective Action
• The paperwork is reviewed and resubmitted by Human Resources
• Permanent Corrective Action
• Workers’ compensation forms are changed so they cannot proceed

without the necessary information.

• Preventative
• The same form becomes mandatory for all departments to submit

with workers’ compensation documentation

Types es o

• f Correc

ective A e Action

• n – Scen

enario

• 2

A road and bridge employee is injured due to improper use of a bench grinder.

• Immediate Corrective Action
• Another employees is assigned the task while the injured

employees receives medical attention.

• Permanent Corrective Action
• The employees of the precinct are trained in the proper use of

bench grinders.

• Preventative
• Power tool safety is made a required training topic for all

employees who may use power tool.

Define the R Root Cause – St Step ep 3 3

• Use the 5 whys to determine symptoms of causes

(the child’s question)

• Brainstorm possible Causes
• Organize causes with Cause and Effect Diagram
• Determine which causes to focus on based on
• Causes occurring most often
• Ease of mitigation of cause
• Understand the root is often a system of causes

The 5 Whys - Scenari rio

Develop

• p Correc

ective A e Action

• n Plan – St

Step ep 4 4

• Solution must eliminate problem
• Verify before implementing
• Determine how we will determine if

solution worked

• Solution cannot create more

problems

• Be Specific
• What is the solution
• Who is responsible
• When will solution be completed

Complete a and Validate Pl Plan – St Step ep 5 5

• Make sure the corrective action

has been implemented fully

• If any measures are not completed,

we need cannot validate

• If any measures cannot be

completed, this may indicate a faulty corrective action

• Validate that the action has

eliminated the problem

• Did the problem reoccur
• Provide evidence
• Document

Scen enario

• – The Barn Burn

rned Down!

Crea eate S Safety Com

• mmittee

e – Pre e St Step ep

• Considering this is a high level incident and that

normal safety committee members may not have the information or experience to handle the matter, we may consider a special committee.

• Who has the information we need.
• Fire Marshall?
• Employee on duty?
• Who has the power to enact changes.
• Commissioner or Engineer in charge of building
• Possibly other court members

Fi Fire Marshall Fi Findings

• Evidence indicated that the fire started at near the

west wall

• Multiple pieces of equipment were on the west wall
• The compressor was damaged but it was not the

source of the fire

• The solvent in the parts washer was an accelerant
• The top of the parts washer was open after the

incident

• No extinguishers were present as they were being

serviced

• The building was built in 2011 in accordance with all

local codes

To Tom’s Te Testimony

• Tom heard noises coming from the shop, including

small explosions

• By the time Tom had eyes on the fire, it was large,

Thought it best to call fire department and evacuate the building

• Tom has experience with fire because last year a he saw

a small fire in the same barn which he put out with an extinguisher

• Last time the parts washer was the only damaged

equipment, it would no longer stay open

• He fixed it with a paper clip and saved the county the

cost of a new parts washer

Iden entify the Prob

• blem

em – St Step ep 1

• Who? – Tom was on site in the office at the time
• What? – The barn burned down
• When? – 8am, just after employees left to a site
• Where? – Road and Bridge Yard
• Why? – Tom’s testimony and fire marshal findings
• How? – To Be Determined
• How many? – Though this is not a frequent problem, this

is a high value loss that could have resulted in the loss of life

Take e Immedia iate e Action – St Step ep 2

• Immediate action was taken by relocating all

equipment to a satellite site that is used for materials storage

• A temporary building was rented to act as office

space.

• All “shop” operations have been indefinitely

suspended.

Define the R Root Cause – St Step ep 3 3

• Why did the shop burn down?
• The west wall caught fire
• Why did the west wall catch fire?
• The solvent in the parts washer was an accelerant
• Why was the solvent an accelerant?
• The parts washer didn’t close to contain fire
• Why didn’t the parts washer close?
• The fusible link was replaced with a paper clip

Define the R Root Cause – St Step ep 3 3

• Why was the fusible link replaced with a paper clip?
• A previous small fire had melted the old clip and Tom

put on a paper clip to hold the lid open.

• Why didn’t Tom replace it with a fusible link?
• Tom did not know what a fusible link was.
• Why didn’t somebody else catch the problem?
• Inspections are not done at this yard.

Develop

• p Correc

ective A e Action

• n Plan – St

Step ep 4 4

Corrective Action 1

• All employees will be trained on all equipment in the

barn that pose any special hazards. This includes: parts washers, air compressors, and any other equipment present.

• Sign in sheets will be kept as documentation to ensure

all employees are properly trained.

• The safety committee will review sing in sheets yearly to

ensure compliance and determine if employees need any other training.

Develop

• p Correc

ective A e Action

• n Plan – St

Step ep 4 4

Corrective Action 2

• The safety committee will work with Road and Bridge

employees to create a checklist that covers all hazards at Road and Bridge

• A weekly inspection schedule will be implemented to

ensure facilities are kept in a safety condition

• The safety committee will review any negative findings

immediately and ensure corrective action is taken.

Complete a and Validate Pl Plan – St Step ep 5 5

• The safety committee has decided to have a special

meeting 1 year from the date of the incident.

• During this meeting, they will be reviewing training

and inspection reports to ensure all training has been done and all negative inspection findings have been completed.

• At this time, the safety committee will determine if

the corrective action has worked, if further action is needed, or if the county can reduce the frequency of inspections and training.

Tha hank nks f for r Attend nding! g!

Southwest

Larry Boccaccio 512-924-4769 larryb@county.org

Southeast

Joseph Szewczyk 512-815-7869 joes@county.org

Northeast

Isaac Garcia 512-573-6596 isaacg@county.org

Northwest

Jack Coffey 512-924-4773 jackc@county.org